Reinsurance Group of America, Incorporated’s Post

Very useful information/ guide for Life and health claims professionals.

https://lnkd.in/gb8a_XHa Sunday Morning Bathroom Read: The bumpy road toward implementing the No Surprises Act took another turn last Friday, October 6, 2023. The US Departments of Health and Human Services (HHS), Labor and the Treasury (collectively, the Departments) provided additional guidance on the qualifying payment amount (QPA) and the independent dispute resolution (IDR) portal. These announcements signal that all stakeholders, including providers, health plans, patients and certified IDR entities, are in for more uncertainty in the days and months ahead. "...With respect to the IDR process, the Departments state that certified IDR entities can still consider the QPA "in light of the TMA III decision" as well as any other relevant factors. Certified IDR entities may request, and disputing parties may provide, additional information relevant to the submitted QPA. So, what does this mean for providers? The Departments are effectively stating that because they don't agree with the TMA III decision and plan to appeal it, they will not actively enforce compliance for at least six months. They describe in the FAQs how difficult it will be for health plans to calculate the QPA without any guidance beyond the language of the No Surprises Act. Thus, while health plans are "supposed to" calculate the QPA according to the methodology as written in the statute, they will not be prosecuted for failure to comply with the rules. Essentially, "enforcement discretion" does not mean no regulation or oversight, but it does indicate that the Departments will take a hands-off approach." It is unclear what remedies providers have at this point. Right now, the only real avenue for redress is a complaint portal that often requires entities to submit individual instances of potential noncompliance without the ability to elevate more egregious disputes. Reading between the tea leaves: It is always better to ask for forgiveness than permission. "Enforcement discretion" = zero enforcement.  This is the provider karma equivalent of informing patients to "please fax to billing department." Cash at the point of service could solve the problem...

5 roles Stats play in EFSA Health Claims Discover insights into avoiding common issues leading to claim rejection: the significance of power calculations, proper randomization, validated methods, and overcoming statistical pitfalls. Our regulatory experts are here to answer all your burning questions! What regulatory questions would you like answered? #clinicaltrials #regulation

In December 2020, Congress enacted the #NoSurprisesAct to protect patients from surprise medical bills in certain circumstances and establish a process for providers and insurers and health plans to determine out-of-network reimbursement. However, the Act's Independent Dispute Resolution (IDR) process has been utilized much more than the Administration projected and as of June 2023, 61% of disputes submitted remained unresolved. In a new white paper, Manatt Health's Nick Bath, Tara Straw and Justine Zayhowski outline consensus approaches to the majority of solutions surrounding the #IDR process.  Learn more and read the full white paper here:

I recently attended the 2023 Centers for Medicare & Medicaid Services Burden Reduction Conference, which hosted several forward-thinking leaders who shared how to optimize healthcare delivery to improve patient lives. To share a success story that resonated with me, Dr. Peter Pronovost highlighted how both internal and external policies can burden care teams. During a time when workforce capacity and productivity warrant major improvements, his team’s exemplary response demonstrated how targeted actions lead to meaningful changes. A team of nurses were asked to brainstorm their most burdensome practices. One of the identified issues was the frequency of recording patient vitals, which often were labeled as standing orders without room for variation. For example, patients were woken from their sleep to address these tasks, although in many cases there were no present clinical indications for doing so. The team constructed an interdisciplinary approach that involved analyses, benchmarking, peer-reviews, changes to autonomy, and more that informed their renewed guidelines. In turn, the team eliminated more than half of these related frequencies, which allowed for 130,000+ hours across the system that the staff could reallocate to patient care. Their call to action not only invited continued collaboration with regulators but also recommended against ambiguous policies that can contribute to overly conservative, wasteful responses. Well done, team. Peter Pronovost Michelle Hereford Jennifer Gonzalez Khaliah Fisher-Grace, PhD, RN All other conference recordings: https://lnkd.in/e-z-a58K

Interesting read…The QALY approach has always sparked controversy, although it is viewed as a key tool for comparing treatments. It would be interesting to see how HTA and value-based assessments will be conducted going forward.

As the landscape of risk adjustment models and regulations evolves, health plans face escalating challenges, necessitating a strategic response. The imperative to address issues such as limited transparency into member data, disjointed processes, insufficient expertise, and customizable program capabilities has become even more critical.   According to CMS, approximately "9.5 percent of payments to Medicare Advantage (MA) organizations are improper, primarily due to unsupported diagnoses submitted by MA organizations." This underscores the urgency for health plans to establish a robust risk program that can adeptly navigate the intricate web of regulatory requirements.   In this on-demand webinar, industry experts from share their perspective on the impact of recent federal regulatory changes, including the RADV Rule and Final Call Letter. Delve into best practices, empowering health plans to enhance the efficiency and effectiveness of their risk adjustment processes, aligning with the evolving regulatory landscape. https://lnkd.in/e655btFT

It's already two weeks into the new year! Time is continuing to fly by. It's time now to be proactive in your health. Don't put off what you can take care of now: schedule your yearly physical and lab work! I know there is a certain level of fear when scheduling a doctor's visit. You worry about the extra appointments that may be scheduled and how much they will cost. It's not that you don't want to take care of yourself, it's that you are concerned with how much it will cost you to do so. That's just one reason I love the DPC model. Your monthly membership fee covers all co-pays and general blood work. You can schedule appointments worry-free knowing it won't cost you any additional money. If additional blood work is necessary, the prices are shared upfront with no hidden fees! It's just one of the many benefits of Direct Primary Care. If you are curious about additional ways the DPC model can benefit you, send me a message with your questions and I'll get you answers!

how many clinical studies require to substantiate a health claim? let's see

Health Plans Need to Take Control! We received this impactful quote from a major TPA while investigating why specific claims are paid egregiously out of line with expectations. This proves why health plans need to improve this shell game and what is leading to medical spend waste in the US! "We can verify if the claim was paid correctly, including confirmation that the reprice amount provided by XXX (parent company) is correct. Outside of that, YYY (TPA) does not negotiate provider contracts nor has no influence on those contracts. Assuming most or all claims are processed correctly, what is your expectation once we have verified if claims have paid correctly based on what we have to work with? Provider contracts are complex and there could be items at play outside of simple fee schedules. XXX (parent company) provider contracts are considered proprietary, even to us as the TPA."